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Questions and Answers
What is the range of normal intracranial pressure (ICP) in mmHg?
What is the range of normal intracranial pressure (ICP) in mmHg?
5-15 mmHg
List two early symptoms that may indicate increased intracranial pressure.
List two early symptoms that may indicate increased intracranial pressure.
Headache and increased blood pressure.
Why is it important to avoid suctioning through the nose in patients with potential CSF leakage?
Why is it important to avoid suctioning through the nose in patients with potential CSF leakage?
It may exacerbate the leakage and cause further complications.
What nursing intervention should be implemented if CSF is detected leaking from the nose?
What nursing intervention should be implemented if CSF is detected leaking from the nose?
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What are two causes of increased intracranial pressure?
What are two causes of increased intracranial pressure?
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What vital sign changes might indicate severe increased ICP?
What vital sign changes might indicate severe increased ICP?
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What position should the head of the bed be elevated to for patients with increased ICP?
What position should the head of the bed be elevated to for patients with increased ICP?
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Name one medication treatment option for increased intracranial pressure.
Name one medication treatment option for increased intracranial pressure.
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What is a craniotomy and what is its primary purpose?
What is a craniotomy and what is its primary purpose?
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List two major risks associated with craniotomy.
List two major risks associated with craniotomy.
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What should nurses encourage patients and their families to do before a craniotomy?
What should nurses encourage patients and their families to do before a craniotomy?
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Differentiate between blunt trauma and penetrating trauma in the context of TBI.
Differentiate between blunt trauma and penetrating trauma in the context of TBI.
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What diagnostic test is most effective for showing cranial fractures?
What diagnostic test is most effective for showing cranial fractures?
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Why should NGT be avoided in patients with potential midface trauma?
Why should NGT be avoided in patients with potential midface trauma?
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What are two signs of increased intracranial pressure (ICP) to monitor in TBI patients?
What are two signs of increased intracranial pressure (ICP) to monitor in TBI patients?
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What supportive care measure might be used for a patient with a GCS score of 8 or less?
What supportive care measure might be used for a patient with a GCS score of 8 or less?
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What is the first-line therapy for treating seizures and its duration of action?
What is the first-line therapy for treating seizures and its duration of action?
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What nursing intervention should be avoided during a tonic-clonic seizure?
What nursing intervention should be avoided during a tonic-clonic seizure?
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List two common symptoms of a spinal cord injury.
List two common symptoms of a spinal cord injury.
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What are the first two steps in nursing intervention for a spinal cord injury?
What are the first two steps in nursing intervention for a spinal cord injury?
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How does a stroke in the left cerebral hemisphere affect the body?
How does a stroke in the left cerebral hemisphere affect the body?
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What immediate treatment is recommended for a stroke within 60 minutes of emergency department arrival?
What immediate treatment is recommended for a stroke within 60 minutes of emergency department arrival?
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What should a nurse do after a seizure to help the patient?
What should a nurse do after a seizure to help the patient?
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Which vertebrae are most commonly injured in spinal cord injuries?
Which vertebrae are most commonly injured in spinal cord injuries?
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What are the key criteria for administering thrombolytic therapy in acute ischemic stroke?
What are the key criteria for administering thrombolytic therapy in acute ischemic stroke?
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List two situations where thrombolytic therapy should not be administered.
List two situations where thrombolytic therapy should not be administered.
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What nursing intervention should be prioritized for patients receiving fibrinolytic therapy?
What nursing intervention should be prioritized for patients receiving fibrinolytic therapy?
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What is a common sign of a ruptured aneurysm in relation to subarachnoid hemorrhage?
What is a common sign of a ruptured aneurysm in relation to subarachnoid hemorrhage?
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Identify one diagnostic test used to identify the site of bleeding in subarachnoid hemorrhage.
Identify one diagnostic test used to identify the site of bleeding in subarachnoid hemorrhage.
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What are the two main management strategies following subarachnoid hemorrhage?
What are the two main management strategies following subarachnoid hemorrhage?
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In the context of transient ischemic attack (TIA), what medication should be administered as ordered?
In the context of transient ischemic attack (TIA), what medication should be administered as ordered?
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What symptom might indicate altered level of consciousness due to subarachnoid hemorrhage?
What symptom might indicate altered level of consciousness due to subarachnoid hemorrhage?
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What is one potential neurological sign associated with Grade 2 bleeding in a patient with an aneurysm?
What is one potential neurological sign associated with Grade 2 bleeding in a patient with an aneurysm?
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Describe one nursing intervention for a patient exhibiting severe bleeding (Grade 4).
Describe one nursing intervention for a patient exhibiting severe bleeding (Grade 4).
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What is one sign indicating a possible increase in intracranial pressure for patients with an aneurysm?
What is one sign indicating a possible increase in intracranial pressure for patients with an aneurysm?
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Which vital sign changes necessitate cardiac monitoring in patients with severe bleeding?
Which vital sign changes necessitate cardiac monitoring in patients with severe bleeding?
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What is a potential consequence of limiting stimulation for a patient with increased intracranial pressure?
What is a potential consequence of limiting stimulation for a patient with increased intracranial pressure?
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Study Notes
Craniotomy
- A surgical procedure to expose the brain by opening the skull.
- The focus of nursing care is before surgery.
-
Risks:
- Infection
- Hemorrhage
- Respiratory compromise
- Increased ICP
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Nursing Considerations:
- Encourage patient and family to ask questions about the procedure.
- Explain that patient's head will be shaved before surgery.
- Patient may be transferred to ICU for close monitoring.
- Provide emotional support.
Cerebral Aneurysm Repair
-
Alternative to surgery:
- Coils can be inserted percutaneously through the femoral artery to occlude the aneurysm.
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Purpose:
- To prevent rupture or rebleeding of cerebral aneurysm.
Traumatic Brain Injury (TBI)
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Types:
- Blunt trauma (closed or open): More common
- Penetrating trauma: A foreign object that penetrates the scalp, skull, meninges, or brain tissue.
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Blunt Trauma:
- Sudden acceleration or deceleration injury.
- Coup: Injury to cranial tissues near the point of impact.
- Countercoup: Impact on the opposite side of the skull, causing a second impact.
Traumatic Brain Injury (TBI) Diagnostic Tests
- Head CT Scan/Cranial CT Scan: Shows cranial fractures
- Cerebral Angiography: Shows location of vascular disruption
- MRI: Can assess axonal injuries
Traumatic Brain Injury Supportive Care Measures
- Close observation to detect neurologic changes.
- Cleaning and debridement of wounds.
- Diuretics: Mannitol/Hypertonic Saline
- Analgesics
- Anticonvulsants
- Respiratory Support: For patients with a GCS score of 8 or less.
Traumatic Brain Injury Nursing Interventions
- Be alert for rate changes or arrhythmias.
- Maintain a patent airway.
- Avoid using NGT in any patient with potential midface trauma.
- Check neurologic status, including pupil size, every 15 minutes.
- Maintain spinal immobilization until the spine has been cleared.
- Observe closely for signs of hypoxia, hypotension, or increased ICP: Headache, dizziness, irritability, anxiety, and changes in behavior.
- Carefully monitor for CSF leakage from the ears or nose.
Traumatic Brain Injury - Positioning
- Elevate the head of the bed 30 degrees.
- Keep the nose and navel in alignment.
- Position the patient to promote secretion drainage.
Traumatic Brain Injury - CSF Leakage
- CSF leakage from the nose: Place a gauze pad under the nostrils. Do not suction through the nose.
- CSF leakage from the ear: Indicates a skull fracture and ruptured tympanic membrane.
Increased Intracranial Pressure
- Pressure produced by the contents within the skull: Blood, CSF, and brain tissue.
- Normal range: 5-15 mm Hg
Increased Intracranial Pressure Causes
- Hemorrhage
- Edema
- Hydrocephalus
- Space-occupying lesions
- Infection
- Metabolic disorders (hepatic encephalopathy)
Increased Intracranial Pressure Assessment
- Patient's level of consciousness, pupils, motor responses, and vital signs.
Increased Intracranial Pressure Early Symptoms
- Headache
- Increased blood pressure
- Nausea and Vomiting
- Motor changes on the side opposite to the lesion
- Change in level of consciousness (restlessness, anxiety, quietness, needs stimulation to be aroused)
Increased Intracranial Pressure Further Compromise
- Hemiparesis: Weakness on one side of the body
- Hemiplegia: Paralysis on one side of the body
Increased Intracranial Pressure Severe Increase
- Absent doll's eye reflex
- Bradycardia: Slow heart rate
- Systolic hypertension
- Widened pulse pressure
- Hyperthermia
- Pupils fixed and dilated
Increased Intracranial Pressure Treatment
-
Osmotic diuresis:
- Mannitol
- Hypertonic saline
Increased Intracranial Pressure Nursing Interventions (General)
- Institute cardiac monitoring and be alert for cardiac changes or arrhythmias.
- Closely monitor vital signs and neurologic status, including LOC and pupil size.
- Maintain a patent airway.
- Monitor oxygenation and ventilation.
- Elevate the head of the bed 30 degrees (appropriate for most patients).
Increased Intracranial Pressure Nursing Interventions (Avoid)
- Avoid extreme hip, knee, and neck flexion.
- Minimize procedures that might increase ICP, such as suctioning.
Seizures
- Abnormal electrical discharge of neurons in the brain.
- IV drugs are always used.
- Ensure patient safety from convulsion trauma.
Seizure First-Line Therapy
-
Diazepam (Valium):
- Given IV in incremental doses.
- Provides 30-40 minutes seizure-free time.
- Lorazepam (Ativan): Longer duration of action.
Tonic-clonic Seizures Nursing Interventions
- Do not restrain the patient during a seizure.
- Place the patient in a lying position.
- Loosen tight clothing.
- Put something soft under the patient's head.
- Clear the area of hard objects.
- Do not force anything into the patient's mouth.
- Turn the patient or the patient's head to the side.
- After the seizure, orient the patient to time and place and inform them they had a seizure.
Spinal Cord Injury
- Includes fractures, subluxations, and dislocations of the vertebral column.
- Most common: Injuries to the 5th, 6th, or 7th cervical; 12th thoracic; and 1st, 4th, and 5th lumbar vertebrae.
Spinal Cord Injury Nursing Assessment
- Muscle spasms and back or neck pain that worsens with movement.
- Point tenderness (pain) on spinal palpation.
- Pain that radiates to other areas, such as the arms or legs.
- Sensory loss.
- Pain, edema, guarding, tenderness over the spine and spinal area.
- Loss of bulbocavernous reflex.
- Neck pain induced by coughing.
- Loss of rectal tone.
- Sensation of hot water or electric shock running down the patient's back.
- Diaphragmatic breathing.
Spinal Cord Injury Nursing Interventions
- Stabilize the spine: Use a cervical collar and backboard.
- If there's a helmet, remove it as possible as per facility protocol (at least 2 people will help.)
- Check the patient's airway and respiratory rate.
- Evaluate the patient's LOC.
- Administer supplemental oxygen as indicated.
- Prepare to administer fluids if the patient becomes hypotensive.
Stroke (Brain Attack)
- Sudden impairment of cerebral circulation in one or more blood vessels.
- Interrupts or diminishes blood supply to the brain causing damage to brain tissues.
-
Causes:
- Thrombosis
- Embolism
- Hemorrhage
Stroke - Hemiparesis
- Stroke in the left cerebral hemisphere produces symptoms on the right side of the body.
- Stroke in the right cerebral hemisphere produces symptoms on the left side of the body.
Stroke Treatment Goal
- Fibrinolytic Therapy (thrombolytics) within 60 minutes of ED arrival.
Stroke Treatment - Medications
- Fibrinolytic (thrombolytics)
- Aspirin (antiplatelet) to prevent recurrent ischemic stroke
- Benzodiazepines for seizure activity
- Antihypertensives _ Anticonvulsants
Stroke - Thrombolytic Therapy
- When to Administer:
- Patient's age is 18 years old and above.
- Acute ischemic stroke.
- Onset of symptoms is less than 3 hours before treatment begins.
Stroke - Thrombolytic Therapy
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Don't Give Thrombolytic Therapy When:
- Subarachnoid hemorrhage happens
- Recent head trauma (within 3 months)
- Uncontrolled hypertension during treatment
- Active bleeding
- Platelet count less than 100,000/mL
- Had heparin administration
- Blood glucose less than 50 mg/dL
Stroke Nursing Interventions
- Secure and maintain the patient's airway.
- Monitor oxygen saturation levels.
- Assess for signs and symptoms of bleeding for patients receiving fibrinolytic therapy every 15-30 minutes.
- If the patient had a TIA, administer antiplatelets as ordered.
- If there are signs of progression, give anticoagulants (heparin).
- Maintain communication with the patient.
Subarachnoid Hemorrhage (SAH)
- Bleeding into the subarachnoid space, where CSF occupies.
- Often associated with aneurysm rupture.
- Most common: Berry aneurysm (saclike outpouching of an artery).
- Remember: Aneurysm rupture usually occurs abruptly without warning.
Subarachnoid Hemorrhage Signs and Symptoms
- Sudden, severe headache
- Nausea and projectile vomiting
- Altered LOC
- Meningeal irritation
- Hemiparesis, hemisensory defects, dysphagia, vision defects, diplopia, ptosis, dilated pupil
Subarachnoid Hemorrhage Diagnostic Tests
- Cerebral angiography - to identify the site of bleeding
- CT scan reveals hemorrhage.
- Lumbar puncture and analysis of CSF
- Transcranial Doppler studies
Subarachnoid Hemorrhage Treatment
-
Five Grades for SAH severity:
- Grade 1 - Minimal Bleeding: Alert, no neurologic deficit, slight headache, and nuchal rigidity.
- Grade 2 - Mild Bleeding: Alert, mild to severe headache, nuchal rigidity, may have 3rd nerve palsy.
- Grade 3 - Moderate Bleeding: Confused, drowsy, nuchal rigidity, mild focal deficit.
- Grade 4 - Severe Bleeding: Stuporous, nuchal rigidity, mild to severe hemiparesis.
- Grade 5 - Moribund: Deep coma or decerebrate.
Subarachnoid Hemorrhage Treatment - General
- Oxygenation and ventilation
- Reduce the risk of rebleeding (attempt to repair aneurysm)
Subarachnoid Hemorrhage Nursing Assessment
- Decreased LOC
- Unilateral enlarged pupil
- Worsening hemiparesis or motor deficit
- Increased blood pressure
- Slowed pulse rate
- Renewed or worsened nuchal rigidity
- Seizures
- Renewed or persistent vomiting
- Worsening headache
- Increased confusion
Subarachnoid Hemorrhage Nursing Interventions
- Establish and maintain a patent airway
- Anticipate the need for supplemental oxygen/mechanical ventilatory support
- Initiate cardiac monitoring and be alert for cardiac changes and arrhythmias.
- Position patient to prevent aspiration and upper airway obstruction.
- Limit stimulation - to minimize risk of rebleeding and avoid increased ICP.
- Monitor LOC and vital signs frequently.
- Avoid rectal temperature measurement.
- Accurately record intake and output.
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Description
This quiz covers essential concepts related to intracranial pressure (ICP), including its normal range, symptoms of increased ICP, and nursing interventions. It also addresses diagnostic tests, craniotomy procedures, and care considerations for patients with potential cerebrospinal fluid (CSF) leakage. Test your knowledge on this critical aspect of nursing care in neurotrauma.
